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Objective: Social determinants of health (SDH) have been shown to correlate with adverse cancer outcomes. It is unclear if their impact goes beyond behavioral risk or healthcare access. We aimed to evaluate the association of SDH with endometrial cancer outcomes in a public healthcare system. Design and Setting: A retrospective cohort study of endometrial cancer patients in Ontario, Canada. Population: Women diagnosed with endometrial cancer in Ontario between 2009-2017. Methods: Clinical and sociodemographic variables were extracted from administrative databases. Validated marginalization scores for material deprivation, residential instability and ethnic concentration were used. Associations between marginalization and survival were evaluated using log-rank testing and Cox proportional hazards regression. Results: 20228 women with endometrial cancer were identified. Fewer patients in marginalized communities presented with early disease (70% vs. 76%, p

Background Adverse childhood experiences (ACEs) are a risk factor for obesity; however, the causal mechanisms are not well understood. Objectives were to measure the impact of ACEs on adulthood obesity and to investigate whether the association was mediated by nutrition and stress. Methods A longitudinal study was conducted using adults aged 46–90 years (n = 26 615) from the Canadian Longitudinal Study on Aging. Participants were asked to recall ACEs from Results There were 66% of adults who had experienced one or more ACE. The odds of obesity defined by BMI and waist circumference increased in a dose–response manner with increasing number of ACEs (P trend Conclusions Adversity experienced in early life is strongly associated with obesity among Canadian adults. Further research is needed to identify other mechanisms for this association to inform obesity prevention strategies.

The aim of this study was to describe sugary drink (beverages with free sugars), sugar-sweetened beverage (beverages with added sugars, SSB) and 100% juice (beverages with natural sugars) consumption across socioeconomic position (SEP) among Canadians.We conducted a cross-sectional analysis of 19,742 respondents of single-day 24-h dietary recalls in the nationally representative 2015 Canadian Community Health Survey-Nutrition. Poisson regressions were used to estimate the prevalence of consuming each beverage type on a given day. Among consumers on a given day, linear regressions were used to estimate mean energy intake. Models included household education, food security and income quintiles as separate unadjusted exposures. Sex-specific models were estimated separately for children/adolescents (2-18 years) and adults (19 +).Among female children/adolescents, the prevalence of consuming sugary drinks and, separately, SSB ranged from 11 to 21 and 8 to 27 percentage-points higher among lower education compared to 'Bachelor degree or above' households. In female adults, the prevalence of consuming sugary drinks and, separately, SSB was 10 (95% CI: 1, 19) and 14 (95% CI: 2, 27) percentage-points higher in food insecure compared to secure households. In males, the prevalence of consuming 100% juice was 9 (95% CI: - 18, 0) percentage-points lower among food insecure compared to secure households. Social inequities in energy intake were observed in female adult consumers, among whom mean energy from sugary drinks was 27 kcal (95% CI: 3, 51) higher among food insecure compared to secure and 35 kcal (95% CI: 2, 67) higher from 100% juice among 'less than high school' education compared to 'Bachelor degree or above' households.Social inequities in sugary drink consumption exist in Canada. The associations differed by SEP indicator. Equitable interventions to reduce consumption are warranted.RéSUMé: OBJECTIF: Dresser le portrait de la consommation de boissons sucrées (boissons contenant des sucres libres), de boissons contenant du sucre ajouté et de jus purs à 100 % (boissons contenant des sucres naturels) chez la population canadienne en fonction du statut socioéconomique. MéTHODE: Nous avons effectué une analyse transversale des rappels alimentaires de 24 heures réalisés par 19 742 personnes dans le cadre de l’Enquête sur la santé dans les collectivités canadiennes – Nutrition 2015, laquelle est représentative de la population nationale. Nous avons utilisé la régression de Poisson pour estimer la prévalence de la consommation de chaque type de boisson durant un jour donné. Pour calculer l’apport énergétique quotidien moyen, nous avons utilisé des régressions linéaires. Les modèles d’analyse traitent la scolarité, la sécurité alimentaire et les quintiles de revenu des ménages comme des expositions non ajustées distinctes. L’analyse en fonction du sexe est divisée en deux groupes, soit les enfants et adolescents (2 à 18 ans) et les adultes (19 ans et plus). RéSULTATS: Chez les filles et les adolescentes, la prévalence de la consommation de boissons sucrées et de boissons contenant du sucre ajouté est plus élevée (de 11 à 21 points de pourcentage et de 8 à 27 points de pourcentage, respectivement) dans les ménages moins scolarisés que dans les ménages plus scolarisés (baccalauréat et études supérieures). Chez les femmes vivant de l’insécurité alimentaire, la prévalence de la consommation de boissons sucrées et de boissons contenant du sucre ajouté est plus élevée de 10 points de pourcentage (IC de 95 % : 1, 19) et de 14 points de pourcentage (IC de 95 % : 2, 27), respectivement, que chez celles qui n’en vivent pas. Chez les sujets masculins, la prévalence de consommation des jus purs à 100 % est moins élevée de 9 points de pourcentage (IC de 95 % : -18, 0) dans les ménages vivant de l’insécurité alimentaire. Nous avons remarqué des disparités sur le plan social dans l’apport énergétique chez les femmes; l’apport moyen provenant de boissons sucrées est plus élevé de 27 kcal (IC de 95% : 3, 51) dans les ménages vivant de l’insécurité alimentaire, et l’apport moyen provenant de jus pur à 100 % est plus élevé de 35 kcal (IC de 95 % : 2, 67) dans les ménages moins scolarisés (pas de diplôme d’études secondaires) que chez les ménages plus scolarisés (baccalauréat et études supérieures). CONCLUSION: Il existe des disparités sur le plan social dans la consommation de boissons sucrées au Canada. Les résultats variaient en fonction de l’indicateur de statut économique. Nous recommandons des interventions équitables pour réduire la consommation de ces boissons.

BACKGROUND The COVID-19 pandemic and associated public health mitigation strategies dramatically changed patterns of daily life activities worldwide. Public health restrictions during the pandemic had unintentional consequences on chronic disease risk factors. Cancer is a leading chronic disease worldwide with several known modifiable risk factors, including smoking, alcohol, poor nutrition, and physical inactivity. OBJECTIVE The study objectives were to conduct a sentiment and emotion analysis using Twitter data to evaluate changes in attitudes towards four cancer risk factors (physical inactivity, poor nutrition, alcohol, and smoking) over time during the first year of the COVID-19 pandemic. METHODS Tweets during 2020 relating to COVID-19 and the four cancer risk factors were extracted from the George Washington University Libraries’ Dataverse. From there, Tweets were defined and filtered using key words to create four unique datasets. We trained and tested a machine learning classifier using a pre-labelled Twitter dataset. This was applied to find the sentiment (positive, negative, or neutral) of each tweet. A natural language processing package was used to identify the emotions (anger, anticipation, disgust, fear, joy, sadness, surprise, and trust) based on the words contained in the tweets. Sentiments and emotions related to each of the risk factors were evaluated over time and word clouds were presented to evaluate common key words that emerged. RESULTS The sentiment analysis revealed that 57% of tweets about physical activity were positive, 16% negative and 27% neutral (n=90,813 tweets). Similar patterns were observed for nutrition, where 55%, 16%, and 29% of tweets were classified as positive, negative, or neutral, respectively (n=50,396 tweets). For alcohol the proportion of positive, negative, and neutral tweets were 47%, 23%, and 30% (from a total n=74,484 tweets) and for smoking the distribution was 41%, 24% and 35%, respectively (n=28,220 tweets). The sentiments were relatively stable over time. Results from the emotion analysis suggest that the most common emotion expressed across physical activity and nutrition tweets was trust, whereas for alcohol the most common emotion was joy and for smoking it was fear. The emotions expressed remained relatively constant over the observed time period. Analysis of the word clouds revealed some further insights into common themes expressed in relation to some of the risk factors and revealed possible sources of bias. CONCLUSIONS The results of this analysis provided insight into the attitudes towards cancer risk factors as expressed on Twitter during the first year of the COVID-19 pandemic. Overall, for all four risk factors, most tweets had a positive sentiment and varied emotions across the different datasets. While these results can play a role in promoting public health, more work is needed to understand how this can be translated into meaningful data to inform public health interventions in a timely manner. CLINICALTRIAL NA

Introduction: Frailty in older adults, characterized by a decline in multiple physiological systems and increasing vulnerability to loss of independence, disability, and death, is a public health priority in developed countries. Etiology of frailty extends across the lifespan and may begin in early life, but empirical evidence for this association is scarce. In this study, we examined whether adverse childhood experiences (ACEs) are associated with frailty in later life. Methods: We conducted a cross-sectional analysis of data for a population-based sample of 27,748 adults aged 45–85 years from the Canadian Longitudinal Study on Aging. The frailty index (FI) was computed with 76 health-related characteristics of physical and cognitive performance, self-rated health, chronic conditions, visual and hearing ability, activities of daily living, and well-being. Self-reported exposure to ACEs included physical, emotional, and sexual abuse, neglect, and witnessing intimate partner violence prior age of 16 and parental death, divorce, and living with a family member with mental illness prior age of 18. Generalized linear regression models with gamma error distribution and identity link function, adjusted for age and sex, were used to examine associations of each ACE type and the number of ACE types (0, 1, 2, or 3+) reported by an individual with FI. All models were adjusted for income, education, smoking, and alcohol consumption in sensitivity analysis. Results: Individuals exposed to ACEs had elevated levels of FI (mean = 0.13, SD = 0.09) than those unexposed, with the largest difference observed for neglect (B [95% CI]: 0.05 [0.04, 0.06]) and the smallest for parental death and divorce (0.015 [0.01,0.02]). The ACE count was associated with frailty in a graded manner, with the FI difference reaching 0.04 [0.037, 0.044] for participants exposed to 3+ ACE types. The association between ACEs and frailty tended to be stronger for women than men and for men aged 45–64 years than older men. Conclusions: Our study supports previous studies showing that exposure to ACEs is associated with frailty in adults. Our findings suggest that screening for ACEs involving childhood maltreatment may be useful for identifying individuals at risk of frailty and prevention of ACEs may have long-term benefits for healthy aging.

Background The effect of being born late preterm (34-36 weeks gestation) on cardiometabolic outcomes across the life course is unclear. Objectives To systematically review the association between being born late preterm (spontaneous or indicated), compared to the term and cardiometabolic outcomes in children and adults. Data sources EMBASE(Ovid), MEDLINE(Ovid), CINAHL. Study selection and data extraction Observational studies up to July 2021 were included. Study characteristics, gestational age, cardiometabolic outcomes, risk ratios (RRs), odds ratios (ORs), hazard ratios (HRs), mean differences and 95% confidence intervals (CIs) were extracted. Synthesis We pooled converted RRs using random-effects meta-analyses for diabetes, hypertension, ischemic heart disease (IHD) and body mass index (BMI) with subgroups for children and adults. The risk of bias was assessed using the Newcastle-Ottawa scale and certainty of the evidence was assessed using the grading of recommendations, assessment, development and evaluation (GRADE) approach. Results Forty-one studies were included (41,203,468 total participants; median: 5.0% late preterm). Late preterm birth was associated with increased diabetes (RR 1.24, 95% CI 1.17, 1.32; nine studies; n = 6,056,511; incidence 0.9%; I2 51%; low certainty) and hypertension (RR 1.21, 95% CI 1.13, 1.30; 11 studies; n = 3,983,141; incidence 3.4%; I2 64%; low certainty) in children and adults combined. Late preterm birth was associated with decreased BMI z-scores in children (standard mean difference -0.38; 95% CI -0.67, -0.09; five studies; n = 32,602; proportion late preterm 8.3%; I2 96%; very low certainty). There was insufficient evidence that late preterm birth was associated with increased IHD risk in adults (HR 1.20, 95% CI 0.89, 1.62; four studies; n = 2,706,806; incidence 0.3%; I2 87%; very low certainty). Conclusions Late preterm birth was associated with an increased risk of diabetes and hypertension. The certainty of the evidence was low or very low. Inconsistencies in late preterm and term definitions, confounding variables and outcome age limited the comparability of studies.

To inform future policies, the study objectives were to determine to what extent the policies included in the 5-year Plan of Action for the Prevention of Obesity in Children and Adolescents-proposed by Pan American Health Organization (PAHO) and signed by 19 Latin America countries in 2014-have been implemented and evaluated.A scoping review of the Governmental websites for Latin American countries and a literature review was conducted to identify whether policies have been implemented and evaluated. Key information was abstracted.The review identified 115 PAHO policies/interventions implemented (43% implemented after signing the proposed plan in 2014). Nearly all (18/19) countries implemented food guidelines or school feeding programs, but fiscal and marketing policies were less commonly implemented (6/19). Through the review, 44 evaluations of PAHO policies were identified of which 23% were qualitative and 77% quantitative. The results of these evaluations were in general positive (e.g., decrease in sugar-sweetened beverages consumption following tax implementation) but no studies evaluated the outcome of reduced obesity.PAHO recommended policies have been implemented to various degrees in Latin America since 2014 and more research is required to understand their impacts on child and adolescent obesity.

Background frailty imparts a higher risk for hospitalisation, mortality and morbidity due to COVID-19 infection, but the broader impacts of the pandemic and associated public health measures on community-living people with frailty are less known. Methods we used cross-sectional data from 23,974 Canadian Longitudinal Study on Aging participants who completed a COVID-19 interview (Sept–Dec 2020). Participants were included regardless of whether they had COVID-19 or not. They were asked about health, resource, relationship and health care access impacts experienced during the pandemic. Unadjusted and adjusted prevalence of impacts was estimated by frailty index quartile. We further examined if the relationship with frailty was modified by sex, age or household income. Results community-living adults (50–90 years) with greater pre-pandemic frailty reported more negative impacts during the first year of the pandemic. The frailty gradient was not explained by socio-demographic or health behaviour factors. The largest absolute difference in adjusted prevalence between the most and least frail quartiles was 15.1% (challenges accessing healthcare), 13.3% (being ill) and 7.4% (increased verbal/physical conflict). The association between frailty and healthcare access differed by age where the youngest age group tended to experience the most challenges, especially for those categorised as most frail. Conclusion although frailty has been endorsed as a tool to inform estimates of COVID-19 risk, our data suggest it may have a broader role in primary care and public health by identifying people who may benefit from interventions to reduce health and social impacts of COVID-19 and future pandemics.

Objectives To examine differences in mental health-related service contacts between immigrant, refugee, racial and ethnic minoritized children and youth, and the extent to which social, and economic characteristics account for group differences. Methods The sample for analyses includes 10,441 children and youth aged 4–17 years participating in the 2014 Ontario Child Health Study. The primary caregiver completed assessments of their child's mental health symptoms, perceptions of need for professional help, mental health-related service contacts, experiences of discrimination and sociodemographic and economic characteristics. Results Adjusting for mental health symptoms and perceptions of need for professional help, children and youth from immigrant, refugee and racial and ethnic minoritized backgrounds were less likely to have mental health-related service contacts (adjusted odds ratios ranged from 0.54 to 0.79), compared to their non-immigrant peers and those who identified as White. Group differences generally remained the same or widened after adjusting for social and economic characteristics. Large differences in levels of perceived need were evident across non-migrant and migrant children and youth. Conclusion Lower estimates of mental health-related service contacts among immigrant, refugee and racial and ethnic minoritized children and youth underscore the importance and urgency of addressing barriers to recognition and treatment of mental ill-health among children and youth from minoritized backgrounds.

Elevated body mass index (BMI) and rapid growth in early childhood are important predictors of obesity risk. The association between maternal preconception BMI and child growth rates is unclear.To assess the association between measured maternal preconception BMI and child age- and sex- standardized WHO BMI z-score (zBMI) growth rates and mean zBMI, in children aged 0-10 years old.A longitudinal cohort study was conducted with children (n = 499) enrolled in The Applied Research Group for Kids (TARGet Kids!) primary care practice-based research cohort. Maternal BMI was measured during the preconception period, defined as the 2 years prior to pregnancy. Repeated measures of child weight and height were obtained between 0 and 10 years of age. Linear mixed models were used to evaluate the association between maternal BMI and child zBMI growth rates and mean zBMI.Maternal preconception BMI was associated with child zBMI growth rate during some growth periods, with the strongest association from age 0 to 4 months; a 5 kg/m2 higher maternal BMI was associated with 0.031 zBMI SD unit/mo higher growth rate (p = 0.004), and 0.186 SD unit higher mean child zBMI (p = 0.0002).Maternal preconception BMI was associated with growth rate and mean zBMI in early childhood. The preconception period may be an important target for health interventions to promote healthy child growth rate and weight outcomes.

BackgroundChildhood obesity is a major public health concern. This study evaluated the independent and joint associations of family-level income, neighbourhood-level income and neighbourhood deprivation, in relation to child obesity.MethodsA cross-sectional study was conducted in children ≤12 years of age from TARGet Kids! primary care network (Greater Toronto Area, 2013–2019). Parent-reported family income was compared with median neighbourhood income and neighbourhood deprivation measured using the Ontario Marginalization Index. Children’s height and weight were measured and body mass index (BMI) z-scores (zBMI) were calculated. ORs and 95% CIs were estimated for the three exposure variables separately using multilevel multinomial logistic regression models with zBMI categories as the outcome, adjusting in model 1 for age, sex, ethnicity and number of family members and in model 2 adding family income. A joint measure was derived combining income and deprivation measures.ResultsA total of 5962 children were included. Low family income (Q1 vs Q5: OR=4.69, 95% CI 2.65 to 8.29), low neighbourhood income (Q1 vs Q5: OR=2.18, 95% CI 1.33 to 3.58) and high neighbourhood deprivation (Q1 vs Q5: OR=2.45, 95% CI 1.52 to 3.95) were each associated with increased OR of child obesity. However, after adjustment for family income, the association for both neighbourhood income (OR=1.39, 95% CI 0.82 to 2.34) and deprivation (OR=1.56, 95% CI 0.94 to 2.58) and obesity was attenuated. Children from low-income families living in low-income or high deprivation neighbourhoods had higher OR of obesity.ConclusionChild obesity was independently associated with low family-level income and a joint measure suggests that neighbourhood also matters. Socioeconomic inequalities at both individual and neighbourhood levels should be addressed in childhood obesity interventions.

Objective Postpartum hemorrhage (PPH) is a preventable condition and the main cause of maternal death worldwide. Evidence on the effectiveness of misoprostol in the prevention of PPH has been generated from both randomized controlled trials (RCTs) and nonrandomized studies (NRS). This study aimed to compare the results of RCTs and NRS, and to compare Classical and Bayesian approaches of combining the results of RCTs and NRS on the use of misoprostol versus placebo in the prevention of PPH. Methods We searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials for appropriate studies. We pooled estimates of effects from RCTs and NRS seperately, using random-effects models, then merged them using classical and Bayesian random effects meta-analysis. Results A total of 34 studies (20 RCTs and 14 NRS) involving 74 204 participants were identified. The summary odds ratio (OR) from RCTs for the use of misoprostol in the prevention of PPH was 0.69 (95% confidence interval [CI]: 0.59 to 0.80). The summary OR from NRS was 0.46 (95% CI: 0.36 to 0.63). Classical and Bayesian approaches of combining the two study designs both showed benefit of misoprostol in preventing PPH, with similar effects. Conclusions Both RCTs and NRS show comparable significant benefit for the use of misoprostol in the prevention of PPH.

Introduction:The authors aimed to examine the association between meeting the integrative movement behavior guidelines (physical activity, screen viewing, and sleep) and cardiometabolic risk (CMR) factors in young children.Methods:In this cross-sectional study, physical activity, screen viewing, and sleep were assessed using parent-reported data. The 24-Hour Movement Guidelines for the Early Years (0–4 y) were defined as 180 minutes of physical activity/day (of which ≥60 min should be moderate-to-vigorous intensity), ≤1 hour of screen viewing/day, and 10 to 13 hours of sleep/night. Waist circumference, glucose, high-density lipoprotein cholesterol, triglycerides, and systolic blood pressure were measured in a clinical setting by trained staff. A total CMR score and individual CMR factors served as primary and secondary outcomes, respectively.Results:Of the 767 participants (3–4 y), 26.4% met none of the guideline’s recommendations, whereas 41.3%, 33.1%, and 10.6% of the sample met 1, 2, or all 3 recommendations, respectively. The number of recommendations met was not associated with the total CMR score or individual CMR factors (P > .05), with the exceptions of high-density lipoprotein (odds ratio = 1.61; 95% confidence interval, 1.11 to 2.33;P = .01).Conclusion:Meeting the 24-Hour Movement Guidelines in early childhood was not associated with overall CMR, but was associated with favorable cholesterol outcomes.

The indirect consequences of the COVID-19 pandemic in older adults, such as stress, are unknown. We sought to describe the stressors and perceived consequences of the COVID-19 pandemic on older adults in Canada and to evaluate differences by socioeconomic factors.We conducted a cross-sectional study using data from the Canadian Longitudinal Study on Aging COVID-19 Exit Questionnaire (September-December 2020). A 12-item checklist was used to assess stressors (e.g., income loss, separation from family) experienced during the pandemic, and a single question was used to measure perceived consequences. We used a generalized linear model with a binomial distribution and log link to estimate prevalence ratios and 95% confidence intervals (CIs) for the association between socioeconomic factors, stressors and perceived consequences.Among the 23 972 older adults (aged 50-96 yr) included in this study, 17 977 (75.5%) reported at least 1 stressor during the pandemic, with 5796 (24.4%) experiencing 3 or more stressors. The consequences of the pandemic were perceived as negative by 23 020 (63.1%) participants. Females were more likely to report most stressors than males, such as separation from family (adjusted prevalence ratio 1.31, 95% CI 1.28-1.35). The perceived consequences of the pandemic varied by region; residents of Quebec were less likely to perceive the consequences of the pandemic as negative (adjusted prevalence ratio 0.87, 95% CI 0.84-0.91) than those of the Atlantic provinces.These findings suggest that older adults across Canada experienced stressors and perceived the pandemic consequences as negative, though stressors and perceptions of consequences varied by socioeconomic factors and geography, highlighting inequalities. Future research will be needed to estimate the impact of stress during the pandemic on future health outcomes.

To investigate whether social determinants of health (SDOH) are predictive of adherence to public health preventive measures and to describe changes in adherence over time among parents and children.A longitudinal study was conducted in children aged 0-10 years and their parents through the TARGet Kids! COVID-19 Study in the Greater Toronto Area, Canada (April-July 2020). This study included 335 parents (2108 observations) and 416 children (2632 observations). Parents completed weekly questionnaires on health, family functioning, socio-demographics, and public health practices. The outcome was adherence to public health preventive measures measured separately for parents and children. Marginal log-binomial models were fitted using repeated measures of the outcome and predictors.Unemployment (RR 0.67, 95% CI: 0.47, 0.97), apartment living (RR 0.72, 95% CI: 0.53, 0.99), and essential worker in the household (RR 0.74, 95% CI: 0.55, 1.00) were associated with decreased likelihood of adherence among parents; however, no associations were observed for other SDOH, including family income and ethnicity. Furthermore, there was no strong evidence that SDOH were associated with child adherence. The mean number of days/week that parents and children adhered at the start of the study was 6.45 (SD = 0.93) and 6.59 (SD = 0.86), respectively, and this decreased to 5.80 (SD = 1.12) and 5.84 (SD = 1.23) by study end. Children consistently had greater adherence than parents.SDOH were predictive of adherence to public health preventive measures among parents but less so in children among our sample of relatively affluent urban families. Adherence was high among parents and children but decreased over time. Equitable approaches to support the implementation of public health guidelines may improve adherence.RéSUMé: OBJECTIFS: Voir si les déterminants sociaux de la santé (DSS) sont des prédicteurs de conformité aux mesures de prévention sanitaire et décrire l’évolution de la conformité des parents et des enfants au fil du temps. MéTHODE: Nous avons mené une étude longitudinale auprès d’enfants de 0 à 10 ans et de leurs parents dans le cadre de l’étude sur la COVID-19 menée par le groupe de recherche TARGet Kids! dans la région du Grand Toronto, au Canada (avril à juillet 2020). L’étude incluait 335 parents (2 108 observations) et 416 enfants (2 632 observations). Les parents ont rempli un questionnaire hebdomadaire sur la santé, le fonctionnement familial, le profil sociodémographique et les pratiques sanitaires. Le résultat était la conformité aux mesures de prévention sanitaire, mesurée séparément pour les parents et les enfants. Des modèles log-binomiaux marginaux ont été ajustés à l’aide de mesures répétées du résultat et des prédicteurs. RéSULTATS: Le chômage (RR 0,67, IC de 95 % : 0,47, 0,97), la vie en appartement (RR 0,72, IC de 95 % : 0,53, 0,99) et la présence d’un travailleur essentiel dans le ménage (RR 0,74, IC de 95 % : 0,55, 1,00) étaient associés à une probabilité réduite de conformité chez les parents; par contre, aucune association n’a été observée pour les autres DSS, dont le revenu familial et l’ethnicité. Il n’y avait pas non plus d’indications convaincantes d’une association entre les DSS et la conformité chez les enfants. Le nombre moyen de jours/semaine où parents et enfants s’étaient conformés aux mesures de prévention sanitaire au début de l’étude était de 6,45 (S = 0,93) et de 6,59 (S = 0,86), respectivement; ce nombre a diminué pour atteindre 5,80 (S = 1,12) et 5,84 (S = 1,23) à la fin de l’étude. La conformité des enfants était uniformément supérieure à celle des parents. CONCLUSION: Dans notre échantillon de familles urbaines relativement aisées, les DSS étaient des prédicteurs de conformité aux mesures de prévention sanitaire chez les parents, mais dans une moindre mesure chez les enfants. La conformité était élevée chez les parents comme chez les enfants, mais elle a diminué avec le temps. Des stratégies équitables d’appui à l’application des directives sanitaires pourraient améliorer le respect de ces directives.

The field of nutritional epidemiology faces challenges posed by measurement error, diet as a complex exposure, and residual confounding. The objective of this perspective article is to highlight how developments in big data and machine learning can help address these challenges. New methods of collecting 24-h dietary recalls and recording diet could enable larger samples and more repeated measures to increase statistical power and measurement precision. In addition, use of machine learning to automatically classify pictures of food could become a useful complimentary method to help improve precision and validity of dietary measurements. Diet is complex due to thousands of different foods that are consumed in varying proportions, fluctuating quantities over time, and differing combinations. Current dietary pattern methods may not integrate sufficient dietary variation, and most traditional modeling approaches have limited incorporation of interactions and nonlinearity. Machine learning could help better model diet as a complex exposure with nonadditive and nonlinear associations. Last, novel big data sources could help avoid unmeasured confounding by offering more covariates, including both omics and features derived from unstructured data with machine learning methods. These opportunities notwithstanding, application of big data and machine learning must be approached cautiously to ensure quality of dietary measurements, avoid overfitting, and confirm accurate interpretations. Greater use of machine learning and big data would also require substantial investments in training, collaborations, and computing infrastructure. Overall, we propose that judicious application of big data and machine learning in nutrition science could offer new means of dietary measurement, more tools to model the complexity of diet and its relations with diseases, and additional potential ways of addressing confounding.

Canadians have been gravely impacted by the COVID-19 pandemic, and adults living with children may have been disproportionately impacted. The objective of this study was to describe changes in chronic disease risk factors and current exercise habits among adults living with and without a child younger than 18 years old.A repeated cross-sectional study was conducted using data collected from Canadians aged 15 and older via the Canadian Perspective Survey Series (CPSS) in late March (CPSS1, N=4,383), early May (CPSS2, N=4,367) and mid-July 2020 (CPSS4, N=4,050). This analysis included participants aged 25 and older. At three points during 2020, participants reported whether they increased, decreased, or had not changed their consumption of alcohol, tobacco and junk food or sweets, their screen use, and whether they currently exercised indoors or outdoors. Behaviours were compared for adults living with and without a child, and unadjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated using logistic regression.The presence of a child in the household was associated with higher odds of increased (compared with decreased or no change) alcohol consumption at all three time points, consumption of junk food and sweets at CPSS1 (OR: 1.69, 95% CI: 1.09-2.60), and time on the Internet at CPSS1 (OR: 1.59, 95% CI: 1.05-2.41) and CPSS4 (OR: 1.56, 95% CI: 1.05-2.29). Compared with older adults (aged 55 and older), younger adults (aged 25 to 54) were more likely to exhibit increases in chronic disease risk factors regardless of the presence of a child in the household.A substantial proportion of Canadian adults reported increased chronic disease risk factors during the pandemic, with greater increases noted among adults living with a child, compared with those living without a child. Public health interventions are urgently needed to mitigate the long-term impact of the pandemic on population health.

Timely surgery has been shown to impact outcome in endometrial cancer patients. Social determinants of health (SDH) are associated with adverse cancer outcomes. We sought to evaluate the association of SDH with surgical treatment indicators in endometrial cancer patients in a public healthcare system.Endometrial cancer patients in Ontario, Canada, diagnosed between 2009 and 2017 were identified, and clinical, social and demographic variables were extracted from administrative databases. Validated community marginalization scores that include material deprivation, residential instability and ethnic concentration were used for stratification. Surgical treatment features were compared across marginalization quintiles using chi-square, Fischer exact or Wilcoxon rank sum tests as appropriate. Predictors of timely surgical treatment were evaluated with logistic regression.20228 patients were identified of whom 14,423 had primary hysterectomy for a preoperative diagnosis of endometrial cancer. Fewer patients in marginalized communities received surgery (89% vs. 93%, p 0.001). Surgical delay was longer among marginalized patients and 78% had surgery within 12 weeks compared to 84% of those least marginalized (p 0.0001). Other quality indicators of surgical treatment were not negatively associated with marginalization. On multivariable analysis adjusted for patient and disease factors, marginalization was independently associated with increased odds of delayed surgery (OR = 0.94/quintile, CI 0.91-0.97, p 0.001).Social marginalization is associated with decreased likelihood of having surgery and with delayed surgery among endometrial cancer patients in Ontario. This may be mediated by delayed presentation and real or perceived barriers to access. Reducing surgical wait times among marginalized cancer patients is an important deliverable in public healthcare.

Background Group‐based trajectory modeling has been applied to identify distinct trajectories of growth across the life course. Objectives of this study were to describe the methodological approaches for group‐based modeling of growth across the life course and to summarize outcomes across studies. Methods A scoping review with a systematic search of Medline, EMBASE, CINAL, and Web of Science was conducted. Studies that used a group‐based procedure to identify trajectories on any statistical software were included. Data were extracted on trajectory methodology, measures of growth, and association with outcomes. Results A total of 59 studies were included, and most were published from 2013 to 2020. Body mass index was the most common measure of growth (n = 43). The median number of identified trajectories was 4 (range: 2–9). PROC TRAJ in SAS was used by 33 studies, other procedures used include TRAJ in STATA, lcmm in R, and Mplus. Most studies evaluated associations between growth trajectories and chronic disease outcomes (n = 22). Conclusions Group‐based trajectory modeling of growth in adults is emerging in epidemiologic research, with four distinct trajectories observed somewhat consistently from all studies. Understanding life course growth trajectories may provide further insight for population health interventions.

Delay in diagnosis of endometrial cancer may be associated with disease progression and impact management and outcomes. Social and cultural barriers influence recognition of symptoms and self-advocacy in seeking care. Associations between social determinants of health (SDH) and disease presentation have been shown in some settings. Our objective was to investigate these in Ontario's universal access system.Endometrial cancer patients in Ontario diagnosed 2009-2017 were identified, and clinical, social and demographic information extracted from administrative databases using ICES (Institute of Evaluative Sciences) algorithms. SDH were quantified using previously validated marginalization indices for material deprivation, residential instability and ethnic concentration. Associations between SDH and disease stage were explored using logistic regression.20,228 patients were identified. 73% of cancers were confined to the uterus. Stage distribution differed across marginalization quintiles (p 0.001) with advanced disease found more frequently in highly marginalized patients: 29% vs. 25% (p 0.001) for material deprivation, OR = 1.06/quintile (CI, 1.03-1.09); 29% vs. 24% (p 0.001) for ethnic concentration, OR = 1.05/quintile (CI, 1.03-1.08); 30% vs. 27% (p 0.001) for residential instability, OR = 1.02/quintile (CI, 1.0-1.05). Marginalization was persistently associated with advanced disease on multivariable analysis adjusted for age, comorbidity score, obesity and disease histology (OR = 1.05/quintile, CI 1.01-1.10, p = 0.03).Socioeconomic marginalization is associated with advanced disease at presentation among endometrial cancer patients in Ontario. Mediators of this association are likely multifactorial, and need to be further investigated in order to create opportunities for improved patient education and advocacy, redistribution of resources and the promotion of health equity.

OBJECTIVES: Interventions for child obesity prevention are needed and it is unclear whether evidence from nonrandomized intervention studies is adequate. The objective of this research was to review the methods for the design, analysis and reporting of nonrandomized intervention studies for child obesity prevention and to assess potential for bias. METHODS: We conducted a review of nonrandomized intervention studies, including population health interventions, quasi-experimental studies and natural experiments, published from 2013 to 2017 that were identified in a recent systematic review. Data on study design, intervention and control groups, outcome measures, and statistical analyses, were extracted. Risk of bias was evaluated using the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool. RESULTS: All identified studies (n = 23) included a school or community-based intervention and had a concurrent control group. Participants were 3–18 years and sample sizes were 100 to > 1 million. Study designs were described inconsistently, and interventions ranged from 14 weeks to 5 years. Obesity was compared between control and intervention groups using logistic or linear regression, analysis of variance and mixed effects regression. Only 48% of studies accounted for clustering, and methods to control for confounding and repeated measures varied substantially. Overall risk of bias was moderate to serious for all studies. CONCLUSION: There are substantial opportunities to improve the methods for nonrandomized intervention studies and reduce bias. Future studies should use advanced statistical and causal epidemiology methods, including better control for confounding and clustering, to generate higher quality evidence and certainty regarding which obesity prevention interventions are effective.

Background There is inconsistent evidence on the association between physical activity and pancreatic cancer risk and few studies have investigated early life or life-course physical activity. The objective of this study was to evaluate the association between trajectories of physical activity across the life-course and pancreatic cancer risk. Methods A population-based case-control study was conducted (2011–2013) using cases (n = 315) from the Ontario Pancreas Cancer Study and controls (n = 1254) from the Ontario Cancer Risk Factor Study. Self-reported recall of moderate and vigorous physical activity was measured at three time points: young adulthood (20s–30s), mid-adulthood (40s–50s) and older-adulthood (1 year prior to questionnaire completion). Physical activity trajectories were identified using latent class analysis. Odds ratios (OR) and 95% confidence intervals (CI) were estimated from multivariable logistic regression adjusted for covariates: age, sex, race, alcohol, smoking, vegetable, fruit and meat consumption, and family history of pancreatic cancer. Results Six life-course physical activity trajectories were identified: inactive at all ages (41.2%), low activity at all ages (31.9%), increasingly active (3.6%), high activity in young adulthood with substantial decrease (13.0%), high activity in young adulthood with slight decrease (5.0%), and persistent high activity (5.3%). Compared to the inactive at all ages trajectory, the associations between each trajectory and pancreatic cancer after confounder adjustment were: low activity at all ages (OR: 1.11; 95% CI: 0.75, 1.66), increasingly active (OR: 1.11; 95% CI: 0.56, 2.21), high activity in young adulthood with substantial decrease in older adulthood (OR: 0.76; 95% CI: 0.47, 1.23), high activity in young adulthood with slight decrease in older adulthood (OR: 0.98; 95% CI: 0.62, 1.53), and persistently high activity (OR: 1.50; 95% CI: 0.86, 2.62). When time periods were evaluated separately, the OR for the association between high moderate activity in the 20s–30s and pancreatic cancer was 0.89 (95% CI: 0.64, 1.25) and some sex differences were observed. Conclusion Distinct life-course physical activity trajectories were identified, but there was no evidence that any of the trajectories were associated with pancreatic cancer. Future studies with larger sample sizes are needed to understand the associations between physical activity trajectories over the life-course and pancreatic cancer risk.

Junior faculty in many universities must go through the promotion process to advance from entry level, e.g., assistant professorship to associate Professor, and ultimately to professorship. The process may often be stressful for some junior faculty, mostly due to some uncertainty about how to optimise their chances of successful promotion. In this paper, we summarise some strategies that would enhance their chances of a smooth promotion based on experiences from junior faculty and senior faculty who have served on tenure and promotion committees. These strategies include understanding the promotion process at your institution; optimizing publications as first or senior author, securing research funding as principal investigator, teaching effectively, providing service efficiently; developing good time management and priority setting skills, finding excellent mentors, and targeting opportunities for collaboration. We also encourage junior faculty to be pro-active about promotion.

Machine learning may improve use of observational data to understand the nutritional epidemiology of cardiovascular disease (CVD) through better modelling of non-linearity, non-additivity, and dietary complexity. Our objective was to develop machine learning prediction models for exploring how nutrients are related to CVD risk and to evaluate their predictive performance. We established a population-based cohort from the Canadian Community Health Survey and measured CVD incidence and mortality from 2004 to 2018 using administrative databases of national hospital discharges and deaths. Predictors included 61 nutrition variables and fourteen socioeconomic, demographic, psychological, and behavioural variables. Conditional inference forest models were interpreted and evaluated by permutation feature importance, accumulated local effects, and predictive discrimination and calibration. A total of 12 130 individuals were included in the study. Use of supplements, caffeine, and alcohol were the most important nutrition variables for prediction of CVD. Supplement use was associated with decreased risk, caffeine was associated with increasing risk, and alcohol had a u-shaped association with risk. The model had an out-of-sample c-statistic of 0.821 (95% confidence interval = 0.801–0.842). Exploratory findings included both known and novel associations and predictive performance was competitive, suggesting that further application of machine learning to nutritional epidemiology may help elucidate risks and improve predictive models. Novelty: Machine learning prediction models were developed for CVD using dietary data. Models were interpreted with interpretable machine learning techniques, revealing diverse associations between diet and CVD. Models achieved comparable or superior predictive performance to existing CVD risk prediction models.

Maternal underweight and obesity are prevalent conditions, associated with chronic, low-grade inflammation, poor fetal development, and long-term adverse outcomes for the child. The placenta senses and adapts to the pregnancy environment in an effort to support optimal fetal development. However, the mechanisms driving these adaptations, and the resulting placental phenotypes, are poorly understood. We hypothesised that maternal underweight and obesity would be associated with increased prevalence of placental pathologies in term and preterm pregnancies. Data from 12,154 pregnancies were obtained from the Collaborative Perinatal Project, a prospective cohort study conducted from 1959 to 1974. Macro- and microscopic placental pathologies were analysed across maternal prepregnancy body mass index (BMI) to assess differences in the presence of pathologies among underweight, overweight, and obese BMI groups compared to normal weight reference BMI at term and preterm. Placental pathologies were also assessed across fetal sex. Pregnancies complicated by maternal obesity had placentae with increased fetal inflammation at preterm, and increased inflammation of maternal gestational tissues at term. In term pregnancies, increasing maternal BMI associated with increased maternal vascular malperfusion (MVM), odds of an appropriately mature placenta for gestational age, and placental weight, and decreased placental efficiency. Male placentae, independent of maternal BMI, had increased inflammation, MVM, and placental efficiency than female placentae, particularly at term. Maternal underweight and obesity are not inert conditions for the placenta, and the histomorphological changes driven by suboptimal maternal BMI may serve as indicators of adversities experienced in utero and potential predictors of future health trajectories.

Background During the COVID-19 pandemic, the public health workforce has experienced re-deployment from core functions such as health promotion, disease prevention, and health protection, to preventing and tracking the spread of COVID-19. With continued pandemic deployment coupled with the exacerbation of existing health disparities due to the pandemic, public health systems need to re-start the delivery of core public health programming alongside COVID-19 activities. The purpose of this scoping review was to identify strategies that support the re-integration of core public health programming alongside ongoing pandemic or emergency response. Methods The Joanna Briggs Institute methodology for scoping reviews was used to guide this study. A comprehensive search was conducted using: a) online databases, b) grey literature, c) content experts to identify additional references, and d) searching reference lists of pertinent studies. All references were screened by two team members. References were included that met the following criteria: a) involved public health organizations (local, regional, national, and international); b) provided descriptions of strategies to support adaptation or delivery of routine public health measures alongside disaster response; and c) quantitative, qualitative, or descriptive designs. No restrictions were placed on language, publication status, publication date, or outcomes. Data on study characteristics, intervention/strategy, and key findings were independently extracted by two team members. Emergent themes were established through independent inductive analysis by two team members. Results Of 44,087 records identified, 17 studies were included in the review. Study designs of included studies varied: descriptive (n = 8); qualitative (n = 4); mixed-methods (n = 2); cross-sectional (n = 1); case report (n = 1); single-group pretest/post-test design (n = 1). Included studies were from North America (n = 10), Africa (n = 4), and Asia (n = 3) and addressed various public health disasters including natural disasters (n = 9), infectious disease epidemics (n = 5), armed conflict (n = 2) and hazardous material disasters (n = 1). Five emergent themes were identified on strategies to support the re-integration of core public health services: a) community engagement, b) community assessment, c) collaborative partnerships and coordination, d) workforce capacity development and allocation, and e) funding/resource enhancement. Conclusion Emergent themes from this study can be used by public health organizations as a beginning understanding of strategies that can support the re-introduction of essential public health services and programs in COVID-19 recovery.

ObjectivesTo describe child and parent weight change during the pandemic, overall and by income precarity.DesignA cross-sectional online survey was conducted.SettingCaregivers of children 0–17 years of age living in Ontario, Canada, during the COVID-19 pandemic from May 2021 to July 2021.ParticipantsA convenience sample of parents (n=9099) with children (n=9667) living in Ontario were identified through crowdsourcing.Primary outcome measureParents recalled, for themselves and their child, whether they lost weight, gained weight or remained the same over the past year. OR and 95% CI were estimated using multinomial logistic regression for the association between income precarity variables and weight loss or gain, adjusted for age, gender and ethnicity.ResultsOverall, 5.5% of children lost weight and 20.2% gained weight. Among adolescents, 11.1% lost weight and 27.1% gained weight. For parents, 17.1% reported weight loss and 57.7% reported weight gain. Parent weight change was strongly associated with child weight change. Income precarity measures, including job loss by both parents (OR=7.81, 95% CI 5.16 to 11.83) and disruption to household food supply (OR=6.05, 95% CI 4.77 to 7.68), were strongly associated with child weight loss. Similarly, job loss by both parents (OR=2.03, 95% CI 1.37 to 3.03) and disruption to household food supply (OR=2.99, 95% CI 2.52 to 3.54) were associated with child weight gain.ConclusionsWeight changes during the COVID-19 pandemic were widespread and income precarity was strongly associated with weight loss and weight gain in children and parents. Further research is needed to investigate the health outcomes related to weight change during the pandemic, especially for youth, and the impacts of income precarity.

IntroductionCardiometabolic diseases, including cardiovascular disease, obesity and diabetes, are leading causes of death and disability worldwide. Modern advances in population-level disease surveillance are necessary and may inform novel opportunities for precision public health approaches to disease prevention. Electronic data sources, such as social media and consumer rewards points systems, have expanded dramatically in recent decades. These non-traditional datasets may enhance traditional clinical and public health datasets and inform cardiometabolic disease surveillance and population health interventions. However, the scope of non-traditional electronic datasets and their use for cardiometabolic disease surveillance and population health interventions has not been previously reviewed. The primary objective of this review is to describe the scope of non-traditional electronic datasets, and how they are being used for cardiometabolic disease surveillance and to inform interventions. The secondary objective is to describe the methods, such as machine learning and natural language processing, that have been applied to leverage these datasets.Methods and analysisWe will conduct a scoping review following recommended methodology. Search terms will be based on the three central concepts of non-traditional electronic datasets, cardiometabolic diseases and population health. We will search EMBASE, MEDLINE, CINAHL, Scopus, Web of Science and Cochrane Library peer-reviewed databases and will also conduct a grey literature search. Articles published from 2000 to present will be independently screened by two reviewers for inclusion at abstract and full-text stages, and conflicts will be resolved by a separate reviewer. We will report this data as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.Ethics and disseminationNo ethics approval is required for this protocol and scoping review, as data will be used only from published studies with appropriate ethics approval. Results will be disseminated in a peer-reviewed publication.

Background There is some evidence that suggests misoprostol may supplement the action of oxytocin in preventing post-partum haemorrhage (PPH). The primary objective of this study was to determine the effect of the administration of 600 μg misoprostol in addition to oxytocin versus oxytocin alone, on the risk of PPH among pregnant women after delivery. The secondary objectives were to determine the effects of the above combination on maternal death and blood transfusion among pregnant women after delivery; and to determine the incidence of PPH, its case fatality, and the maternal mortality ratio in our hospital. Methods Design and setting: Retrospective chart review of 1736 women delivering at the Regional Hospital Bamenda Cameroon, between 2015 and 2016. This was a pre versus post study following a policy change in the prevention of PPH. Exposure groups: One group received oxytocin-misoprostol (January–April 2016: period after policy change), and the second group received oxytocin-only (January–April 2015: period before policy change) after delivery. Outcomes: The primary outcome was PPH, and the secondary outcomes were maternal death and blood transfusion. Statistical analysis: A 1:1 matching with replacement was done with the propensity score (PS). The groups were compared using PS matching with conditional logistic regression on the matched pairs as the main analysis. A sensitivity analysis was done using other PS adjustment methods and multiple regression. Results Of the 1736 women included in this study, 1238 were matched and compared. Women who received oxytocin-misoprostol were less likely to have PPH as compared to those receiving oxytocin-only (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.08, 0.59, p = 0.003). This reduced odds of PPH was upheld in the different sensitivity analyses. There were no significant differences in the odds of maternal death and the use of blood transfusions between the two groups: OR 3.91, 95% CI [0.44, 35.08], p = 0.22, and OR 0.89, 95% CI [0.14–5.63], p = 0.91, respectively. Sensitivity analyses showed similar results. The incidence of PPH was 2.9% (before adding misoprostol the incidence was 4.4% and after adding misoprostol it was 1.5%), the case fatality rate of PPH was 1.96%, and the overall maternal mortality ratio in the hospital was 293 maternal deaths/100000 life births. Conclusion Our evidence suggests that using 600 μg misoprostol as an add-on to oxytocin in the prevention of post-partum haemorrhage significantly reduces the odds of PPH without affecting other maternal outcomes.